[December 22, 2004] "The President remains in superb physical condition," said Adam M. Robinson, Jr., commander of the National Naval Medical Center in Bethesda, MD, after the president's fourth annual physical at the center on December 11.

"The doctors said that Mr. Bush had a 'low' to 'very low' risk of coronary artery disease, although they found evidence of minimal calcification of the coronary arteries themselves. As a preventative, they recommended that Mr. Bush take a daily aspirin and a statin, or cholesterol-lowering drug," reported the New York Times.

It's interesting that his doctors advised him to take aspirin and statin. Aspirin is used to prevent clotting, which is a problem with AF (the condition he apparently wears the LifeVest for). Statins are the most potent cholesterol-lowering agents, lowering LDL (so-called "bad cholesterol) by 30-50 percent. They are less effective than fibrates in lowering triglycerides and raising HDL ("good cholesterol"). But Bush's doctors said he had a "low" to "very low" risk of heart disease, and his total cholesterol level was listed as 170 mg/dL, which is considered within the normal range.


There is ongoing research into other areas where statins appear to have an effect, including dementia. Science Daily recently reported (11/17/04): "The cholesterol-lowering drug atorvastatin slowed down mental decline and improved depressive symptoms in people with Alzheimer’s disease"

In contrast to the "fit for duty" report, the photos below show Mr. Bush at a presidential debate, with parts of a LifeVest wearable defibrillator clearly visible underneath his suit jacket.



The LifeVest (left) has an electrode belt with four sensing/ECG electrodes. These send signals to the heart monitor/defibrillator, typically worn like a holster. When the monitor detects a life-threatening heart arrhythmia, it send a signal to the small, handheld patient-interface module (a little like a computer "mouse" but with just buttons and alarms). The module provides an audible alarm. The user, if able to do so, depresses two buttons on the module to hold off a shock from the defibrillator. If the user faints and is unable to press the buttons, the defibrillator sends an electrical pulse to the large shocking electrode on the patient's back and a smaller one on the chest. The pulse can be repeated until the heart starts pumping blood effectively, up to five pulses.

In the center photo, showing Mr. Bush and Sen. Kerry at a debate, one can clearly see the shocking electrode between the shoulder blades as well as the electrical cord leading down to the monitor/defibrillator.

The photo on the right, from another debate, gives another view of the LifeVest components.

Below we see the president adjusting his necktie, and as he does so, revealing a gray cord like that on the interface module ("mouse"), leading down to the monitor/defibrillator. The interface module possibly was located behind his tie.



This news could turn out to be the story of the year -- for 2005 -- if reporters ask the right questions to the right people.

Some time between the fainting (pretzel) incident of January 2002 and the following summer, the president apparently began wearing the device. The photo of Mr. Bush at his ranch was taken on August 9, 2002.



THE FAINTING INCIDENT OF JANUARY 2002

On January 13, 2002, President Bush lost consciousness while sitting on a couch in the White House, watching a football game. His head hit the floor, resulting in an abrasion on his left cheekbone and a small bruise on his lower lip. The incident was blamed on a combination of (a) Mr. Bush not feeling well in previous days and (b) an improperly eaten pretzel. Their combined effect was to slow the president's heart. The description suggests a vasovagal attack: A pretzel lodged in his throat stimulated the vagus nerve to send a signal to his heart, slowing it down and reducing blood flow so much he fainted, according to White House physician Col. Richard J. Tubb, M.D.



Of course, even in this day of e-medicine, it is difficult and uncertain for anyone to diagnose a patient without having access to examination and test records. That doesn't stop physicians and psychologists from trying, especially on someone with President Bush's visibility. Obviously, considerable testing and examination have been done; but the American public does not always have the latest results, as they found out after other presidents, including Roosevelt and Kennedy, left office. Besides photographic evidence, there are observations and quotes from doctors, based on hours of Bush TV appearances, voluminous reports in the media, and the president's own words.

ATRIAL FIBRILLATION (AF)

In the January 2002 pretzel-choking episode, according to President Bush, the period of unconsciousness was brief -- a few seconds. When fainting begins and ends suddenly, the cause of fainting usually is not what his doctors reported (vasovagal syncope) but instead is an abnormal heart rhythm such as atrial fibrillation (AF). Chronic AF is consistent with Mr. Bush's requirement for constant monitoring and immediate access to defibrillation. Atrial fibrillation can lead to disastrous consequences if the patient is capable of sustaining a very rapid preexcited ventricular response with conduction over the accessory pathway. The rapid heart rate can produce syncope (fainting); or, more important, AF may cause ventricular fibrillation and sudden cardiac death. The LifeVest the president wears terminates ventricular fibrillation or ventricular tachycardia (overspeed) to prevent sudden cardiac death. This may be the reason the president wore the device during the debates, even though he risked exposing his vulnerability, especially if the device alarm sounded.

According to the Framingham Offspring study of AF, a person whose parent had AF is 50 percent more likely to have it than the general population. President Bush's father had it during his presidency. While jogging at Camp David on a Saturday afternoon (May 4, 1991), Bush Sr developed shortness of breath, chest tightness, and a general feeling of fatigue. A White House physician discovered Bush had a rapid irregular heartbeat, ultimately diagnosed as atrial fibrillation caused by Graves' disease, a form of hyperthyroidism (overactive thyroid).

Vagal-mediated AF is a well described phenomenon and often occurs in older athletes, which our current president, George W. Bush, is. As far as treatment, there are many different drug options. Blood thinners are often prescribed to reduce the risk of blood clots. President Bush's latest medical report (December 2004) included advice to take aspirin, which is a well known anti-clotting agent. Clotting can lead to strokes, discussed later.

Although atrial fibrillation usually is controllable with treatment, it may become a lasting, chronic, condition. In the president's case, it apparently has, as his physicians evidently have decided to have him wear an external device that can continuously monitor his heart and shock it back into effective operation in case of an attack.

Hyperthyroidism, hypertension, and other diseases can cause arrhythmias, as can recent heavy alcohol use (binge drinking). Some cases have no identifiable cause. The president says that he stopped drinking when he was 40, so binge drinking is not an issue. However, both of his parents have the Graves' disease form of hyperthyroidism and it is hereditary and must be considered.

The earliest photo I have seen of President Bush wearing the LifeVest was the one taken in August 2002. He probably started wearing the LifeVest between the January 2002 pretzel incident and this. The most likely time would seem to be after his June 28, 2002 colonoscopy, for which he was put under anesthesia at Camp David, MD -- that is, some time in July 2002.

At any rate, the president bears watching for symptoms of AF, which include: heart palpitations (sensation of rapid heartbeat), irregular pulse, shortness of breath (especially during physical activity or emotional stress), chest pain (angina), weakness and fatigue, dizziness and confusion, lightheadness, or confusion. If the condition remains untreated, serious complications may occur, including stroke, heart attack, and heart failure.

EVIDENCE OF STROKE OR TIA
The evidence of atrial fibrillation is strong, based on photographic evidence that Mr. Bush wears an anti-arrythmic device, his father's having it, a confirmed sudden-fainting spell, numerous falls, and observation-at-a-distance. The evidence of a stroke or TIA is less strong. It is symptomatic and based observation-at-a-distance -- TV appearances and news reports -- but it is there.

A stroke or TIA (transient ischemic attack) is one possible consequence of AF itself. A TIA basically is a mini-stroke.

Many observers, including physicians, have been concerned or even alarmed at the symptoms President Bush has evidenced in TV appearances.

The photo below shows the drooping mouth noticed by Dr. W. Kendall Tongier, M.D. of Dallas, Texas.



After watching the third presidential debate, Dr. Tongier posted on the Dallas Morning News website about his concerns that the president may have had a stroke. Dr. Tongier has been an anesthesiologist for 15 years. His post said:

"Having watched the first two debates from start to finish, I was looking forward to listening to a spirited debate between Bush and Kerry. Unfortunately, I barely heard a word that was said. Instead, I found myself staring at and concentrating on the president's drooping mouth."


"As a physician and a professor, I tend to pick up on signs and symptoms of physical problems better than most other people. I am highly concerned with what I saw. The drooping left side of the President's face, his mouth and nasolabial fold (the crease in the face running from the nostril to the side of mouth) may be indicative of a recent stroke, TIA (transient ischemic attack) or, possibly botox injections. I sincerely hope this was nothing more than botox injections. The other options are truly scary given an upcoming election for president in three weeks."

In a phone interview reported by Salon.com, Dr. Tongier stressed that he's not a neurologist, and no doctor can make a diagnosis from a 90-minute debate. But he did explain why he found Bush's face so distracting on TV: "It struck me across the face to the point where I wasn't really listening to the debate. It looked like the left side of his mouth was downturned. You know how he sneers at times. At first I thought that's what it was, but it didn't change when his face was at rest. It changed when he talked, but you'd expect that. It's the loss of muscle tone there that's really kind of concerning. And it was pretty much persistent throughout the entire debate."


"It certainly could be something as benign as an overzealous botox injection, which causes the paralysis, which is essentially how botox works. A lot of people will get them around the nasolabial fold to decrease those lines. If it's botox, it can be a short-term reaction after an injection. It could last for 24 hours and be gone. But I'd like to see the Bush campaign at least give an explanation."

Not only was there no explanation, but the president delayed his annual medical examination until after the election. Even now, as far as I know, the complete details, including tests made and the metrics of those tests, have not come out -- only a conclusion that he is in "supurb condition." If the speculation is true, the writers of the president's medical report should be held to account for the discrepancies.

Atrial fibrillation is an irregular heartbeat in which the upper chamber of the heart quivers rapidly rather than beats. Even if it does not result in life-threatening ventricular fibrillation, the quivering motion is not forceful enough to send all the blood to the heart's lower chambers (ventricles), and the blood pools, thus allowing clots to develop. The clots can migrate elsewhere, including the neck or brain (in cerebral embolism), and they can cause strokes.

A series of strokes can cause a progressive impairment of brain function known as "multi-infarct dementia."

DEMENTIA

The term "dementia" refers to a group of symptoms involving progressive impairment of all aspects of brain function. Disorders that cause dementia include conditions that impair the vascular (blood vessels) or neurologic (nerve) structures of the brain. Multi-infarct dementia results from the damage caused by strokes, and there is evidence that Mr. Bush has suffered multiple small strokes or TIAs.

One other type of dementia is caused by Wernicke encephalopathy, which is bleeding and swelling of the brain due to multiple brain lesions, caused by lack of thiamine vitamin. The disease often is connected to alcoholism. Mr. Bush drank, often heavily, according many published reports, from about age 20 to age 40. He said himself one time that he couldn't remember a day he didn't have a drink.

A minority of causes of dementia are treatable. Wernicke can be treated with thiamine. If untreated long enough, the disease progresses to Korsakoff's disease, which like most of the disorders associated with dementia are progressive, irreversible, degenerative conditions.

The two major degenerative causes of dementia are (1) Alzheimer's disease, which is a progressive loss of nerve cells without a known cause or cure, and (2) vascular dementia, which is loss of brain function due to a series of small strokes. Vascular dementia may or may not play a role in the progression of Alzheimer's disease: the conditions often occur together and neither can be diagnosed definitively except until autopsy. In those with the genetic and environmental susceptibility to develop Alzheimer's disease, the concomitant presence of small infarcts (lacunar strokes) speeds up the onset of Alzheimer's disease to an earlier age than if it were to occur alone (i.e., without small infarcts). President Bush has been prescribed statins, which slow the progression of dementia, even though is over all cholesterol is within the normal range.

Dementia may be diagnosed when there is impairment of two or more brain functions, including language, memory, visual-spatial perception, emotional behavior or personality, and cognitive skills (such as calculation, abstract thinking, or judgment). Dementia usually appears first as forgetfulness. Other symptoms may be apparent only on neurologic examination or cognitive testing.

A well-respected psychoanalyst has written a psychological profile of the president, called "Bush on the Couch: Inside the Mind of the President" (ISBN: 0060736704).

Justin A. Frank, M.D., is a clinical professor in the Department of Psychiatry at George Washington University Medical Center. Since 1980 he has been a teaching analyst at the Washington Psychoanalytic Institute. He is past president of the Greater Washington Chapter of Physicians for Social Responsibility. Dr. Frank lives and practices psychoanalysis in Washington, D.C.

Among the problems Dr. Frank found in Mr. Bush are megalomania, characterized by a Manichaean worldview, delusions of persecution and omnipotence, and an "anal/sadistic" indifference to others’ pain. The Manichaean tradition is a defunct religion with a "good cop/bad cop" theology.

The book follows Mr. Bush from childhood to now and analyzes the drinking problem, the bellicose rhetoric, the verbal flailings and misstatements of fact, the religiosity and exercise routines, the hints of dyslexia and hyperactivity, the youthful cruelty to animals and schoolmates

Below are some of the problems associated with dementias, including vascular and alcoholic (Wernicke-Korsakoff syndrome). Some of the things in this list were observed by Dr. Frank in Mr. Bush. Other items exist further along in the progression of the disease.

- progressive loss of memory
- inability to concentrate
- decrease in problem-solving skills and judgement capability
- persistence in failed problem-solving modes, "staying the course" at all costs (perseveration)
- confusion
- hallucination, delusions
- altered sensation or perception
- impaired recognition (agnosia) of familiar objects or persons
- altered sleep patterns
- MOTOR SYSTEM IMPAIRMENT
-----gait changes
-----inappropriate movements
-----other impairments of motor system
- disorientation
- inability to generalize, learn, think abstractly, or perform calculations
- MEMORY DEFICIT
----- short term (can't remember new things)
----- long term (can't remember past) Persons with this may make up stories to cover up nothing but the memory lapse itself. (confabulation)
- IMPAIRED LANGUAGE ABILITY
----- inability to comprehend speech
----- inability to read (alexia)
----- inability to write (agraphia)
----- inability to find words (aphasiia)
----- inability to repeat a phrase
----- persistent repetition of phrases or words (Much has been made of President Bush's use of the word "fabulous.")
- PERSONALITY PROBLEMS
----- irritability
----- poor temper management
----- anxiety
----- depression
----- indecisiveness
----- self-centeredness
----- inflexibility
----- no observable mood (flat affect)
----- inappropriate mood or behavior
----- withdrawal from social interaction
----- inability to function in social or personal situations
----- lack of spontaneity

Some of the above have been noted by Dr. Frank in the Bush book. Some have been noted by other MD's and by medical laymen, including members of the press.

Evidence of motor-system impairment has been well chronicled by the media. Most of these incidents have come at times of particular stress. They include:

January 2002: While watching a football game, Mr. Bush fainted and injured his face. This was a time of stress, 2 weeks before his post-9/11 State of the Union address.

May 2003: Mr. Bush fell off a Sedgway gyroscopically balanced 2-wheel scooter. Another stress -- 2 weeks before a trip abroad to line up support for Iraq war.

August 2003: Mr. Bush dropped his dog Barney as Mrs. Bush handed him the dog at the TSTC Airport in Waco, Texas, to the horror of onlooking schoolgirls. In little over a week he would give only his second (the first was to announce the start of the war on Iraq) address to the nation defending the yellowcake/Wilson/Plame matter, the WMD deadend, and the growing insurgency in Iraq -- arguably his most important national address to date. This was a time of stress.

May 2004: Two days before one of very few and arguably the most important prime-time speech of his, in which he defended the Iraq war in the wake of Fallujah and Najaf unrest, Mr. Bush fell and injured his face again. His approval rating was 41 percent, the lowest of his presidency, at this time of stress.

June 4, 2004: Mr. Bush appeared with a scatch on his right cheek. Had he fallen again?

Additional symptoms that may be associated with this organic brain disease include swallowing problems. However, this and some of the above are also symptoms of hyperthyroidism.

HYPERTHYROIDISM (OVERACTIVE THYROID)

When one of a person's parents has hyperthyroidism, one cause of AF and the cause in his father's case, the chances are that 50 percent of their children will have it. Both of President Bush's parents have Graves' disease, increasing his chances of getting it even more.

The president's father was diagnosed with Graves' disease, a form of hyperthyroidism in 1991, within 18 months of Barbara Bush being diagnosed with the same thing. The chances of this happening to two unrelated persons in such a short time is about 1 in 3 million. Because of the remarkable coincidence, the Secret Service tested the water in the White House, at Camp David, at the Vice President's residence, and at Walker's Point (Bush's home in Maine) for lithium and iodine, two substances "known to cause thyroid problems." The lead investigator was Dr. Kenneth Burman, then a colonel in the Army medical corps (the same man whom the media is quoting about the thyroid cancer of Chief Justice Rehnquist).

Besides causing atrial fibrillation as it did in the case of Bush Sr and possibly Bush Jr, hyperthyroidism has the following symptoms:

-- Feeling of fullness in the throat

-- Enlargement of the thyroid, known as goiter

-- CHOKING ON FOODS

-- Irregularities in blood pressure and HEART RATE.

-- FAINTING OR DIZZINESS

-- SENSITIVITY TO LIGHT AND A CONTINUAL FEELING THAT THERE IS SOMETHING IN THE EYES (This could explain the president's rapid eye-blinking, noted in the presidential debates.)

The onset of Graves' frequently is during times of intense stress. Bush Sr fell ill with Graves' and AF during the first Iraq war.

The president's physicians should be looking carefully at his thyroid antibodies and conducting a complete thyroid bloodwork panel in view of his symptoms and family history. Of course, Mr. Bush should level with the American people on this.


OTHER SYMPTOMS OF HYPERTHYROIDISM

Enlarged thyroid gland

Rapid heart beat (tachycardia) or heart palpitations

ATRIAL FIBRILLATION (President Bush appears to have worn a LifeWest defibrillator since about July 2002.)

Smooth, velvety skin

Tremor of the fingertips

Fatigue

SWEATY PALMS -- This is related to heat intolerance.

Weight loss

Fine brittle hair

RESTLESSNESS -- Some observers noted this during the debates.

Depression

Increased appetite

Changes in sex drive

MUSCLE WEAKNESS, ESPECIALLY IN THE UPPER ARMS AND THIGHS -- The president did drop his 15-pound dog during a handoff from his wife as mentioned above. Also, he has replaced a large part of his running regimen with mountain-bike riding, which, as noted, has resulted in one injurious accident.

Shortened attention span.

HEAT INTOLERANCE -- In the Bush-Kerry camps' agreement for the 2004 debates, one requirement was that the temperature be kept below 70 degrees. This requirement apparently came from the Kerry camp since Sen. Kerry supposedly sweats easily. However, this would also serve Mr. Bush's interest if he has hyperthyroidism.

INCREASED SWEATING

NERVOUSNESS AND IRRITABILITY -- This is one of the symptoms that also has a neurological etiology.

Restless sleep or insomnia -- Mr. Bush does arise at 5 a.m., at least at his ranch.

ERRATIC BEHAVIOR -- Besides hyperthyroidism, this obiously also is a symptoms of Wernick-Korsakoff syndrome (alcoholic syndrome) as well as various dementias including multi-infarct dementia.


CONCLUSION

The president apparently uses a wearable defibrillator, a device to stop heart arrhythmia, as seen in photographs. He has had a sudden fainting spell and other symptoms of atrial fibrillation (AF) and has a genetic tendency for it. Some observers have noted neurological and psychological irregularities and other evidence of stroke, which is a possible result of AF. Some of these irregularities could be caused by Wernicke-Korsakoff's, a disease of inveterate alcoholics, or some other organic brain disease. The president has an even stronger genetic predisposition for hyperthyroidism and some symptoms of it, including the heartbeat arrhythmia. Only his doctors know for sure.